Even As COVID-19 Ebbs, Nursing Homes Struggle

The third year of a planned five-year project by researchers with the University of Michigan turned out to be a doozy. They were investigating infection prevention and control practices in 58 nursing homes in Michigan to see how those institutions managed urinary tract infections (UTIs) and catheter-associated urinary tract infections (CAUTIs). Karen Jones, MPH, RN, CIC, is with the department of internal medicine at the University of Michigan and one of the authors of a study presented today at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC). Jones said that the third year of the study began on March 1, 2020, and end on February 28, 2021, and was supposed to include face-to-face meetings between hospital officials, and nursing home administrators and infection preventionists (IPs). “We were able to conduct one live in-person conference,” Jones recalls. “And that was a big component of this AHRQ [Agency for Healthcare Research and Quality] project is to have face-to-face infection prevention and control education…. [W]e had our very first [COVID-19] case identified in Michigan only a few days later.” The rest of the meetings were held virtually and investigators continued to collect data on the 16 nursing homes involved in that third year that reinforced what’s well-known in health care: That many nursing homes don’t have certified IPs and those that do will find that there’s a high IP turnover rate. “The nursing homes that we surveyed had almost two thirds of their nursing home infection preventionists turn over in the course of just 12 months,” Jones tells Infection Control Today®. “Keeping someone in that role is very, very important.” In general, even with virtual meetings, Jones believes that nursing homes benefited. “I think it was even more important during that time of COVID to build those relationships, to have open lines of communication, especially when it came to things like personal protective equipment (PPE) allocation, and visitation, staff education,” Jones tells ICT®. “It did benefit everyone to have those relationships strengthened during COVID year.”

Infection Control Today®: So, in a nutshell, what you what you find in your study?

Karen Jones MPH, RN, CIC: Well, this is part of a much larger project that the University of Michigan is conducting. It’s a five-year long AHRQ sponsored project that is looking to see across the years, what kind of infection prevention practices are being done in nursing homes. And what kind of relationships we could help to bridge between their local hospitals and the nursing homes. The data that we’re presenting here at APIC is part of a smaller initial survey that we gave to nursing homes that were enrolling in this 12-month long project. And it asked different things as far as their facility demographics, their infection prevention and control program, their enrollment and CDC’s NHSN [the Centers for Disease Control and Prevention’s National Healthcare Safety Network] surveillance processes, and different types of UTI prevention. And we presented what we found in those first three years. And again, that’s all pre-COVID. And we found some interesting things as it relates to nursing home outcomes and process measures.

ICT®: It was all pre-COVID. Did you think when COVID arrived, and all the focus all of a sudden turned toward nursing homes that you may have stumbled onto something bigger than you originally planned to study?

Jones: Yes, for sure. But our project team [members] were there to support nursing homes. We had to be very nimble in what we did as far as our project because research projects saw a lot of changes that needed to be implemented during COVID. But one of the things is that we started to provide some virtual-type education to again support those nursing homes during the pandemic.

ICT®: When we’re talking about stronger ties between nursing homes and hospital systems, are we talking about University of Michigan hospital system?

Jones: Well, for this project year, we are not. We don’t have Michigan Medicine, the actual hospital, enrolled. We actually have a total of [58] nursing homes throughout Southeast and Mid-South Michigan that are enrolled. And we’ve had a total of 12 hospital systems or health systems that have been part of this three-year-long project. We’ve branched out much, much further beyond just the University of Michigan to get a better picture of what’s going on in Michigan nursing homes and hospitals.

ICT®: How did those nursing homes do when COVID-19 struck? Was there any noticeable difference between how they fared compared to other nursing homes in the state?

Jones: Yes, we kept a real strong relationship with the 16 nursing homes that were enrolled for that particular project year. Our project year actually began on March 1, 2020. We were able to conduct one live in-person conference. And that was a big component of this AHRQ project is to

Karen Jones MPH, RN, CIC

have face-to-face infection prevention and control education. That was the one and only face-to-face one we were able to have because we had our very first [COVID-19] case identified in Michigan only a few days later. But one of the things that we were able to do—again, we switch to all virtual—but we definitely included those hospital representatives. And I think it was even more important during that time of COVID to build those relationships, to have open lines of communication, especially when it came to things like personal protective equipment (PPE) allocation, and visitation, staff education. It was it did benefit everyone to have those relationships strengthened during COVID year. So, the 58 nursing homes were over a span of three years. We’re going to be continuing to collect the data that was presented at this year's APIC conference for an additional one or two years. But for this particular project year that began again in March [2020], they’re part of that larger 58 nursing home cohort.

ICT®: The study, as you mentioned, was part of a project and that project was trying to help nursing homes improve their rates as far as hand hygiene, and PPE usage. And it mentioned that there seems to be a lack of education for staff. Now, how is that addressed? And was that improved by the project?

Jones: Well, a big thing that we found through our surveys is that leadership staff were not always aware of … they may have been aware of infections, but they were not aware of proper hand hygiene, proper gown and glove use. And those were the things that we really hammered home for this particular project. Our staff would go in and actually conduct educational seminars on proper hand hygiene and gown and glove use. But it really was up to nursing home leadership to understand the importance of these correct process measures to get to the proper outcome measures of reduced infections.

ICT®: Will there be data collected to find out whether what was taught stuck? And did those nursing homes fare better than the national average of other nursing homes in terms of how COVID-19 was handled?

Jones: Well, that’s really outside of the scope of this particular project. One of the things that we are going to be doing is an exit survey of those nursing homes. That’s actually in progress right now. And what we’ll be looking at is…. We won’t be looking at actual hand hygiene rates of health workers at those particular nursing homes. But we’ll be looking to see if nursing homes have had a greater focus on what those rates might be. So that would mean are nursing homes now paying attention, doing audits on hand hygiene and gown and glove use, among other things related to infection prevention and control. Are they aware of how their health care workers are performing hand hygiene and is it adequate?

ICT®: Nursing home leadership. What was the response when you pointed out some of the gaps in care? How did they respond to that?

Jones: They actually were not too surprised. I think nursing homes overall have many different issues. And when it comes to infection prevention and control, they want to do the best thing. Sometimes it’s awareness of what the best evidence-based practices are. Sometimes it’s just bringing awareness to the fact that they really need to put a focus on infection prevention. And I think the COVID pandemic has really sped all of that along. You know, I think one of the issues that nursing homes had during the pandemic was that they were getting so many different messages from so many directions, that it was very difficult for them to keep track of things, to properly disseminate the information that they were receiving. And guidance was changing so rapidly. It was very difficult for nursing home leadership to stay on top of things. You know what we tried to do, again with those 16 nursing homes that were enrolled during that project year of COVID, is that we tried to provide a summary or synopsis as we were able to, to just give them the highlights on what’s new, what’s changed, and do the best we could to help them along during the pandemic.

ICT®: As I mentioned in the introduction, as I’m sure you’re well aware, APIC is lobbying states to do things. For instance, anybody who’s called infection preventionist should have CIC after their name. And that nursing homes should have a fulltime infection preventionist on staff. What was your experience? Did you see many infection preventionists on staff in nursing homes?

Jones: Yes. So, it wasn’t presented in this year’s APIC abstract. But we have previously talked about how nursing home infection prevention programs have struggled. We know that the staff turnover rate while in nursing homes is generally pretty high. The nursing homes that we surveyed had almost two thirds of their nursing home infection preventionists turn over in the course of just 12 months. Keeping someone in that role is very, very important. Because they need to be properly educated, they need to have the time given to them to not only get education, but to set up their program and properly run it and not to be pulled in many different directions when it comes to being at work. Meaning if they’re an infection preventionist that’s what they need to focus on. They should not also be responsible for all different tasks in the nursing home.

ICT®: Any idea why there were such high turnover? Were they just exhausted?

Jones: It’s hard to say. We did some qualitative research on the topic. But they left for a multitude of different reasons. And again, as I mentioned, nursing home staff turnover is notoriously high. What I’d be very interested in learning about is what’s happened during—and now as we are getting to a little bit of a plateau with the pandemic and hopefully seeing cases dip down even lower—is that going to lead to even more staff turnover particularly when it comes to infection prevention and control? They were really the ones that had even more responsibilities and had to work with both health care workers, deal with family members, leadership, and also keep on top of the rapidly changing and often conflicting guidance that they were receiving from all different entities.

ICT®: If nursing homes reached out to you now, what would you tell them? What would be your bullet points of advice?

Jones: Well, I would tell them to keep up the good work. That it has been a year like none other. I would suggest to them, if they’re able to, they should participate in some sort of quality improvement programs such as what our team at the University of Michigan offers that can provide them free support and guidance toward evidence-based best practices as it relates to infection prevention and control. And has a strong track record of working with nursing homes, knowing their day-to-day struggles, and working with them to be able to provide the safest care for their nursing home residents.

ICT®: Would it be simple steps first? Like shore up your hand hygiene compliance rates?

Jones: Yes, but they need support to be able to do that. We can direct them to different resources. There are many different resources. One of the big ones is the Clean Hands Count Campaign by the CDC. Just for them to be aware of everything that’s been created that’s available out there for free distribution for anybody in nursing homes to be able to use. Definitely, it’s very important for nursing home leadership to take the stand of making infection prevention and control a priority at their facility. And one of the biggest parts of that is to identify and then support those infection preventionists and to partner with them to make sure that the information is going down to health care workers, to residents, and again to visitors and family members that are coming into the facility.

ICT®: Are you as an infection preventionist concerned that society as a whole will lose sight of the important steps in infection prevention? Will practices start to drift at acute care hospitals? And especially nursing homes? Are you worried that they might go back to the bad old ways of doing it? I mean, if they ever got out of the bad old ways of doing things?

Jones: Oh, yes, for sure. And I think there’s that burnout. There’s that fatigue for health care workers. It has been a very, very rough 14 to 15 months for health care workers. It’s so critical that we keep up this heightened awareness of infection prevention measures. Things will change. They’re going to de-escalate. And we need to roll with it. It’s really key to have a good written infection prevention and control plan at the hospital level but then also at the nursing home level. And what keeps that up to date? It’s an infection preventionist who’s knowledgeable, who’s been educated, who’s been trained, who’s certified. And then also the support from their leadership to keep that up to date, and to be able to transition to whatever happens next. Not just with a pandemic, but with everything in infection control.

This interview has been edited for clarity and length.